DR. GIRISH MOTWANI Consultant Foot & Ankle surgeon (Paediatric & Adult) 1)Sushrut Hospital, Research Centre & PostGraduate Institute of Orthopaedics, Nagpur west 2)Aman hospital,Nagpur east 3)South point clinic, Nagpur south

1. Calcaneum fracture-
pathoanatomy & various fracture pattern.
DR. GIRISH MOTWANI
Consultant Foot & Ankle surgeon
(Paediatric & Adult)
1)Sushrut Hospital, Research Centre &
PostGraduate Institute of Orthopaedics,
Nagpur west
2)Aman hospital,Nagpur east
3)South point clinic, Nagpur south
Qualifications
o MS orthopaedics (Gold medalist)
o Fellowship in Foot & Ankle ortho
(university of Alabama at Birmingham ,USA)
o Fellowship in paediatric ortho
(B.J.wadia hospital for childrens ,Mumbai)
o Certification in Ankle sports medicine
(Northwestern university ,Chicago,USA)

4. Calcaneum fracture
“The man who
breaks his heel
bone is done “

5. • 2 % of all fractures
• Most commonly fracture tarsal
bone.
• 60 % of tarsal fracture
• 75 % are displaced
intraarticular fracture.
Calcaneum fracture

6. ANATOMY
• TUBEROSITY
serves as attachment for achillis tendon & plantar
fascia.
• ANTERIOR PROCESS
1.Articulates with cuboid (CC joint).
2.Origin for extensor digitorum brevis muscle belly.
• SUSTENTACULUM TALI
1.Support middle facet of talus.
2.Fulcrum for FHL tendon.
3.Close relationship with posterior tibial nerves &
terminal branches of tibial nerve.

7. ANATOMY
• POSTERIOR FACET
Support the talar body
• ANTERIOR & MIDDLE FACETS
“Form the sustentaculum tali constant fragment”
Bear more weight per unit area than the posterior facet.
NORMAL FUNCTION OF SUBTALAR JOINT RELIES ON
RESTORATION OF THE RELATIONSHIP OF THESE JOINTS

8. Anatomy
• POSTERIOR FACET slopes downward
posteriomedially.
• Difficult to visualize intraoperatively.
• Must be awake to avoid intraarticular
screw placement.
POSTERIOR
FACET
MEDIAL
(SUSTENTACULUM)
LATERAL

9. Vascularity
1. lateral calcaneal artery(LCA) – Br. Of peroneal A
2. lateral malleolar artery(LMA) – Br. Of anterior tibial A
3. lateral tarsal artery(LTA) – Br. Of dorsalis pedis A
The lateral calcaneal artery appeared to be responsible for
“majority of the blood supply to the corner of the flap”
and, because of its proximity to the vertical portion of the
typical incision, it appeared most likely to be injured from
inaccurate placement of the incision.
LCA

10. ANATOMY
• More than just a bone.
• Thin soft tissue envelop.
• Multiple structure at risk.
• Sural nerve & posterior
tibial tendons at particular
risk with lateral dissection.

11. •How does a displaced
intraarticular calcaneum
fracture disrupt normal
anatomy?

12. HIGH ENERGY AXIAL LOADING( MVA, FALL FROM HEIGHT)
LATERAL PROCESS OF TALUS DRIVEN INTO ANGLE OF GISSANE, ACTS AS WEDGE
Primary fracture line from anteriolateral to
posteriomedial

13. PRIMARY FRACTURE LINE
AMF
PLF

14. Secondary fracture line runs in
one of two planes,depending
on direction of force
1)beneath the facet exiting
posteriorly in Tongue-type
fracture
2) behind the posterior facet
in Joint depression fractures
SECONDARY FRACTURE LINE dectates whether there is joint
depression or tongue-type fracture

15. SECONDARY FRACTURE LINE dectates whether there is joint
depression or tongue-type fracture
NO ESSEX
LOPRESTI
TECHNIQUE FOR
JOINT
DEPRESSION
TYPE

16. CONSTANT FRAGMENT -Sustentaculum
Location of this fragment
and the density in this
area are critical For
reduction and fixation of
calcaneal fracture
SUSTENTACULUM
Typically maintains
Its relationship with
Talus via interosseous
Ligament & medial joint
capsule

17. Coronal Axial Sagittal
Pathoanatomy of calcaneum fracture

18. Broden’s view
• Positioning
20° IR view (mortise)
10°-40° plantar flex
Demonstrating the
articular surface of the
posterior facet.

19. Harris axial view
• Very difficult to obtain in the acute setting
• 45° axial of heel
• 2nd toe in line w/ tibia
Assess varus/valgus
-- Normal »10° valgus –
Joint displacement
Tuberosity angulation
Heel width.

20. • Bohler’s angle
• 20-40
• Gissane’s angle
• 95-105
Lateral view
Lateral view

21. Sander’s classification
Sanders R, Fortin P, DiPasquale T et-al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a
prognostic computed tomography scan classification. Clin. Orthop. Relat. Res. 1993; (290): 87-95. Pubmed citation
It is based on the
coronal CT scan which
shows the widest
under-surface of the
posterior facet for the
talus.
1)number of
intraarticular fracture
lines and
2)their location on
semicoronal CT
images.

22. Sander’s classification
Sanders R, Fortin P, DiPasquale T et-al. Operative treatment in 120 displaced intraarticular calcaneal
fractures. Results using a prognostic computed tomography scan classification. Clin. Orthop. Relat. Res.
1993; (290): 87-95. Pubmed citation
”This classification is useful not only in understanding
typical fracture patterns of the calcaneus, but also in
predicting outcome.
As you move from type 1 to type 4 injuries, expected
outcomes are progressively worse”

23. Sander’s classification

24. “We conclude that, despite the popularity of the classification system of Sanders
for intra-articular fractures of the calcaneum, there is a high degree of variability
and inconsistency in its interpretation with only a fair to moderate agreement
among its users. Our aim is neither to advocate this system nor to undermine it, but
to highlight its shortcomings so that caution is exercised in its usage and
interpretation.”
Published 14 January 2005

25. Consistent features
• There is significant variability in the fracture pattern of displaced
intraarticular calcaneal fractures however there are 3 consistent
features…
1) sustentaculum typically remain attached to the talus.
2) The anterior process translates dorsally.
3) The tuberosity translates laterally,displaces superiorly (pull of
achillis),rotates into varus and shortens into the fracture.

26. Extraarticular calcaneal fracture
Medial process
fracture
Anterior process
fracture
Verticle tuberosity
fracture
Avulsion fracture at
EDB attachment

27. ANTERIOR PROCESS OF CALCANEUM
FRACTURE

28. SUSTENTACULUM TALI FRACTURE Tuberosity avulsion fractures
Due to axial loading and inversion
Usually treated conservatively with non weight
Bearing or fixed by screw
Associated FHL tendon injury
• Achilles avulsion
• Wound problems
• Surgical urgency
─ Lag screws or tension band

29. Take home message…..
• When calcaneum fracture occurs, the heel can widen, shorten, and
become deformed. Consider all pathoanatomical features of fracture to
evaluate its complex geometry.
• Although there is significant variability in the fracture pattern of
displaced intraarticular calcaneal fractures, always look for 3 consistent
features – sustentaculum,anterior process & tuberosity varus.
• Defining calcaneal fracture in different xray views & CT scan is crucial
part in its management.

30. THANKS